Provider Demographics
NPI:1710107438
Name:SEACOAST PSYCHOLOCIAL ASSOCIATES, INC.
Entity Type:Organization
Organization Name:SEACOAST PSYCHOLOCIAL ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GRAD
Authorized Official - Middle Name:LEO
Authorized Official - Last Name:FLICK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:228-435-2673
Mailing Address - Street 1:983 HOWARD AVE
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39530-3756
Mailing Address - Country:US
Mailing Address - Phone:228-435-2673
Mailing Address - Fax:228-435-2674
Practice Address - Street 1:983 HOWARD AVE
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39530-3756
Practice Address - Country:US
Practice Address - Phone:228-435-2673
Practice Address - Fax:228-435-2674
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS26352103TC0700X
MSC09141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00017976Medicaid